Recovery-Oriented Practices Index: Development, Use, and Role in Policy Implementation Anthony D. Mancini, PhD Teachers College, Columbia University April 30 th, 2007 Scottish Recovery Indicator Conference
Outline of Talk 1. Background on theory and research on recovery-orientation 2. Development process for recoveryoriented practices index (ROPI) 3. Modifications for the Scottish Recovery Index (SRI) 4. Use of the ROPI (or SRI) 5. Description of system-level changes in New York
Background on Recovery Orientation Mental health recovery: Increasing focus of mental health policy in the US, UK, and around the world Traces to consumer-survivor literature and longitudinal studies on recovery from severe mental illness No single criterion often self-determined As process (non-linear, personal journey, embrace of hope, overcoming effects of institutionalization) As outcome (fulfillment of life roles, reduced involvement in formal services, greater self-agency) As transaction with environment (rejection of normal, acceptance of limitations, supportive relationships, role of policy-making)
Background on Recovery Orientation Despite varying definitions, some common themes have emerged: Identity formation (mental illness one facet of a more differentiated self) Autonomy/self-agency (greater capacity for selfinitiated action; internal vs. external motivation) Hope (renewed sense of possibility) Supportive-healing relationships (both professional and personal) Enhanced role functioning (employment, parenthood)
Background on Recovery Orientation Indeed, the process of recovery has been welldescribed but what are its implications for mental health organisations and carers? One obvious implication is that organisations should seek to leverage their services to enhance these facets of recovery. But how? And is there evidence that recovery-enhancing strategies would work?
Background on Recovery Orientation The fullest representations of humanity show people to be curious, vital, and self-motivated. At their best, they are agentic and inspired, striving to learn; extend themselves; and apply their talents responsibly Yet, it is also clear that the human spirit can be diminished or crushed and that individuals sometimes reject growth and responsibility
Background on Recovery Orientation The fact that human nature can be either active or passive, constructive or indolent suggests more than mere dispositional differences It also bespeaks a wide range of reactions to social environments Social contexts catalyze motivation and personal growth. (Ryan & Deci, 2000)
Background on Recovery Orientation Self-determination theory (SDT) provides a theoretical framework for recovery-orientation (Ryan & Deci, 2000): A motivational theory of human need fulfillment Three fundamental human needs: 1) autonomy, 2) competence, and 3) relatedness Satisfaction of these needs promotes well-being, feelings of security, and self-motivated behavior
Background on Recovery Orientation Empirical findings on SDT: Behavioral management of diabetes is predicted by perceptions of an autonomy-supportive health care environment Employees that report more need satisfaction (autonomy, competence, and relatedness) show better objective job performance Learning environments characterized by more autonomy support result in deeper processing of material, better test performance, and more persistence Enhancing autonomous motivation results in better treatment retention for substance abuse programs Many other studies have confirmed SDT s postulates
Background on Recovery Orientation Conclusion: Mental Health organisations can address these basic human needs through their services, policies, and underlying philosophy Broadly speaking, recovery-oriented practices are intended to enhance service users feelings of autonomy, competence and relatedness
Developing a Scale for Recovery- Oriented Practices Six Steps: 1) Identified 11 prior self-report recovery scales and 4 typologies of recovery practice 2) Content analysis and classification of items across scales (e.g., consumer involvement in treatment, use of self-help, family involved in services, employment services) 3) Further refinement based on latent content (e.g., choice, community integration) 4) Principles of recovery-orientation abstracted based on latent themes 5) Item construction to capture principle 6) Subsequent refinement through expert review and further revision
Developing a Scale for Recovery- Oriented Practices Eight principles* of recovery-oriented care resulted: 1. Meeting basic needs 2. Comprehensive services 3. Customization and choice 4. Consumer involvement and participation 5. Network supports/community integration 6. Strengths-based approach 7. Self-determination 8. Recovery focus *The SRI uses these same principles but with different language appropriate to the Scottish service context
Developing a Scale for Recovery- Oriented Practices We translated the 8 principles by focusing on basic program functions: Nature of services Documentation (assessment, care plans) Policies and procedures Program brochures, literature Staffing 20 items emerged with 5-point behaviorally anchored response alternatives Approach was modeled on fidelity scales, which have demonstrated the value of an organisation-level assessment
Developing a Scale for Recovery- Oriented Practices: Validation We piloted the ROPI at a variety of mental health programs in New York State (N = 14) Assertive community treatment (ACT) Day treatment Vocational Consumer-run clubhouse Most programs were participating in large New York State policy initiative New licensed program type designed to embody recovery principles Personalized Recovery Oriented Services (PROS) ROPI used as an evaluation tool for this initiative
Developing a Scale for Recovery- Oriented Practices: Validation To assess construct validity, we used the recovery selfassessment scale (RSAS), a self-report measure for recovery-oriented practices RSAS was administered to staff and administrators We examined the program-level association between the RSAS and ROPI scores A strong correlation emerged (r =.74, p <.01) Finding demonstrated that staff reports of recovery orientation were consistent with the organization-level data of the ROPI
Developing a Scale for Recovery- Oriented Practices Modifications: ROPI SRI SRI is substantially the same as the ROPI Changes reflect different cultural and service contexts (e.g., consumers vs. service users ) Some additional content was added (e.g., regarding supervision) Overall, changes are minor and the instruments are essentially equivalent
Using the ROPI (or SRI) 4½ 6 hours to complete At least 2 surveyors Three separate processes: 1) Interviews with senior administrators, carers, and service users 2) Document review, including a) treatment records; b) policy manuals; c) program materials brochures, newsletters, etc. 3) Consensus scoring based on accumulated data while on site
Using the ROPI (or SRI) Interviews (2-3 hours) Senior administrators or managers (1-1.5 hrs) Organization-level philosophy of care Policies relating to care provision Treatment services provided Carers (.50 -.75 hrs) Nature of services (e.g., type of services and degree of personalisation) Service users (.50 -.75 hrs) Perception of services (e.g., personalised, goal focus, involvement of support system)
Using the ROPI (or SRI) Review of documentation and materials (about 2 hrs): 10 treatment records/care plans (1.25 hrs) Program policy manual (.5 hrs) Program documentation, brochures (.25 hrs)
Using the ROPI (or SRI) Scoring (1 hour) Done at conclusion of visit Based on accumulated data and subjective impressions Surveyors share impressions and arrive at consensus for scoring each of the indicators
Using the ROPI (or SRI) Feedback to program: Brief report itemizing SRI scores Cite data and observations to support scores Invoke broader themes and encouraging findings Concrete suggestions (e.g., care plans more personalised) Meet with senior managers to communicate findings
Implementing Change in New York State: Lessons from Two Initiatives Recovery-Oriented Practices Initiatives: 1. Personalised Recovery-Oriented Services (PROS) program Mandated restructuring to consolidate diverse program types (e.g., vocational, consumer-run, and day treatment) Fiscal guidelines created incentives (and requirements) for recovery-oriented practices ROPI used as an evaluation tool to measure pre- and postrecovery orientation Initiative is ongoing
Implementing Change in New York State: Lessons from Two Initiatives 2. Assertive Community Treatment (ACT): Community-based model of care for persons with severe mental illness Created a fiscal structure for community-based services New program license Hired consultants and trainers to help programs meet standards and understand the ACT model Used audits and technical assistance to promote adherence to the practice model
Implementing Change in New York State: Lessons from 2 Initiatives New York s approach emphasized fiscal restructuring and program monitoring Audits monitored program adherence to ACT model Poor scores were linked to sanctions Approach was more stick than carrot
Implementing Change in New York State: Lessons from Two Initiatives Some Drawbacks of New York s approach: Standards for practice were implemented inflexibly and varied by administrative region Negative audits had a demoralizing effect on administrators and practitioners Heightened tensions between providers and NY state Reified practice standards
Implementing Change in New York State: Lessons from Two Initiatives Some conclusions: A more supportive approach that emphasized partnership would have been more effective Implementation of policy should be consistent with the policy itself Service providers and administrators should be empowered to make choices
Final Thoughts Recovery-oriented practices are: Increasingly agreed-upon Supported by theory and research Measurable at the organisation level An index of recovery-oriented practices can: Orient providers to basic practices and principles Mark change over time Be used collaboratively and supportively Form the basis for further discussion and refinement of ideas regarding practice